The world’s first smartphone video app to support patients to complete tuberculosis treatment

A team of researchers from The Farr Institute in London, in partnership with the NHS, are testing a mobile app that could help patients with managing their tuberculosis treatment.

The Challenge

Tuberculosis (TB) is an infectious disease that is spread in tiny droplets in our breath mainly during coughing. Even though effective treatments to kill TB bacteria are available, in 2014, 9.6 million people became infected with TB and 1.5 million people died from TB-related causes worldwide.

A 6-month course of medication to treat TB disease can be prescribed but it can be very difficult to support people to continue to take their medication over this period of time. If patients repeatedly miss their treatment doses, the TB bacteria can become resistant to the medication. Drug-resistant TB is harder to treat because the medicines used to treat it are less effective, need to be taken for longer, may need to be given as injections and have more side effects. Failure to take regular treatment can also lead to spread of infection to other people.

Given these treatment challenges, the World Health Organisation recommends Directly Observed Therapy (DOT) to manage the treatment of TB. This involves a healthcare worker or another responsible adult observing a patient, in person taking their TB medication. In the UK, DOT is recommended for people who may have complicated social problems and may find it difficult to stay on their treatment, such as those with a history of being homeless or unstable home environments, drug use and imprisonment. It is also recommended for people with drug resistant disease.

There is a lot of mixed evidence on whether DOT improves cure rates or reduces the risk of TB re-lapsing. Having to travel to a clinic each day is expensive and to be observed taking their treatment can sometimes make patients feel like they are being treated unfairly. It is also difficult and expensive for clinics to deliver DOT.

The Research

As mobile phone apps and tablet computers become more widely available, it has been possible for a team of researchers at the Farr Institute in University College London and other research partners to develop an alternative solution, called Video Observed Therapy (VOT). As part of the NIHR TB Reach programme a team of Farr researchers at UCL in partnership with the London based NHS Find&Treat TB service are leading the world’s first randomised controlled trial of VOT for TB. This uses a smartphone app developed by the University of San Diego. Randomised controlled trials are widely accepted as the gold standard method for evaluating effectiveness of health treatments and technologies.

Participants agreeing to take part in the study are randomly selected to either have their treatment observed with in-person face-to-face DOT or with VOT. Those using VOT are given a smartphone with a pre-installed VOT app allowing participants to record themselves taking their tablets. Using the smartphone the video-clips of each treatment dose are time-stamped and sent automatically to the research team. These clips are viewed each day by the research team, who also provide training to participants to make sure that the video-recording steps are followed to allow the team to reliably assess whether the medication has been taken.

The Results

Findings from the trial so far show that VOT is an acceptable and flexible alternative to DOT. Participants of the trial have taken part in research study interviews, reporting,

“I was getting tired of DOT. I thought I would be a lot freer to continue with my daily life—all that time and effort you’ve saved me—I didn’t need much convincing. With the DOT, it felt like…there was some kind of stigma and for that reason they are monitoring you. It felt like being a criminal”.

Importantly, the intervention also involves some in-person interaction with the VOT observers.

Another participant said,

“I wouldn’t have felt comfortable just meeting a person online—I would have been like, ‘who’s that person, I don’t even know him?’ But I’m really pleased you came all the way to my house, to make me comfortable and show me what to do… and I took it from there and it was really good.”

The Impact

The study and has generated a great deal of interest from the World Health Organisation and TB services internationally. The research team are actively involved in working with the World Health Organisation to develop the global strategy to end TB using digital health.

Following early promising results the WHO have recommended that VOT may be used as an alternative to DOT for the supervision of tuberculosis treatment in settings which are able to provide this. London Clinical Commissioning Groups have also agreed to fund a pan-London VOT service.